r.i.c.e.

Authors: Nikhil Srivastav, Lovey Pant, Aditi Priya, Diane Coffey

Working Paper

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Abstract:

In the last 15 years, there has been a large increase in facility births and a large decline in home births across India. In Uttar Pradesh (UP), increases in facility birth have led to puzzlingly little decline in neonatal mortality.

This paper investigates the role of private facilities in providing care at birth to rural residents of UP. At least one in five births to rural UP residents takes place in a private facility. These births experience a stunningly high neonatal mortality rate of 65 deaths per 1000, compared to 40 among births in public facilities, and 47 among home births.

This research seeks to understand why mortality rates are higher in private facilities than public facilities. We document some selection of complicated cases into private facilities; some reasons for this are public employees’ risk avoidance, referral commissions and staffing shortages.

Yet selection is not the only reason for the private-public mortality gap: We document abysmally poor quality of care in private facilities. Private providers serving rural residents are largely untrained and unregulated. They have financial incentives to over-intervene in birth, which patients support because they conflate intervention with care. Despite the inadequacy of care in public facilities, public facilities are nevertheless safer for rural babies.

We recommend that governments increase financial incentives to families and ASHAs for public facility births and that civil society groups warn rural families about the dangers of giving birth in private facilities.